Vtt 275 Surgical Nursing

Front 1

Immediate Supervision - Definition

Back 1

The vet is within direct eyesight and hearing range.

Front 2

Duties Permitted Under Immediate Supervision

Back 2

- Cast/splint application
- Dental extractions
- Anesthesia induction
- Surgery assistance
- Euthanasia

Front 3

Direct Supervision - Definition

Back 3

The vet is on the premises and is readily available.

Front 4

Duties Permitted Under a Minimum of Direct Supervision

Back 4

- Intubation
- Blood administration
- Fluid aspiration from a body cavity (no thoracocentesis or abdominocentesis)
- Monitoring vital signs
- Application of a cast for the immobilization of a fx (after repair)
- External, non-invasive ultrasonography
- Tasks listed with a minimum of indirect supervision if the animal is anesthetized (a vet must be on the premises if the animal is anesthetized anyway)

Front 5

Indirect Supervision - Definition

Back 5

The vet is not on the premises but the tech is able to perform the duties by maintaining direct communication

Front 6

Duties Permitted With a Minimum of Indirect Supervision

Back 6

- Teeth cleaning
- Enemas
- EKG
- Bandage application
- Catheterization of an unobstructed bladder
- Introduction of a stomach tube
- Ear flushing with pressure or suction (aftter the vet has verified the tympanic membrane is intact)
- Radiograph positioning and machine operation

Front 7

Duties Permitted With a Minimum of Indirect Supervision - cont.

Back 7

- Administration of oral and rectal radio-opaque materials
- Administration of oral and topical meds, including controlled substances
- IV fluid administration
- Blood, urine, skin, parasite and microorganism collection for analysis
- Collection of tissue during or after a necropsy performed by a vet
- IM, SQ, or IV injections
- IV catheter placement

Front 8

LVT's Role in Surgical Nursing - The Pre-Op Period

Back 8

- Help obtain patient info through history, PE, and diagnostic tests
- Care of the patient including IV catheter, administration of meds, etc.
- Maintenance of anesthesia machine and prep of the surgery room with the necessary equipment - packs, sutures, blades, towels, etc.
- Induction of anesthesia as per DVM instructions

Front 9

LVT's Role in Surgical Nursing - Intra-Op

Back 9

- Scrub nurse: sterile assistant who aids Dr. in retraction, stabilization, hemostasis, and whatever else the Dr. dictates

Front 10

LVT's Role in Surgical Nursing - Post-Op

Back 10

- Cleaning the patient: removing any blood residue, urine or fecal matter (always express bladder before SX)
- Placing necessary bandages: such as tail wraps post-docking and foot bandages post-declawing.
- Recovering the patient including extubation and staying with the patient until he/she is calm.

Front 11

LVT's Role in Surgical Nursing - Post-Op (cont.)

Back 11

- Keeping the patient comfortable and clean, and administering any RX meds until the patient is discharged (comfort included pain meds, comfy bedding, positioning to prevent pressure sores, helping to stand and move)
- Discharging the patient (if the DVM doesn't) and informing the owner of instructions and care of the post-surgical patient.
- Cleaning the surgery room and instruments; making and autoclaving surgical packs

Front 12

The Minimum Patient Database

Back 12

- History
- Surgical procedure to be performed
- Complete PE
- Diagnostic tests a per DVM
- Determination of the patient's physical status and anesthetic risk

Front 13

Patient History

Back 13

- Avoid yes or no questions; ask open-ended questions
- Confirm procedure(s); sometimes receptionist doesn't get it all; write it down
- Confirm age of the animal - stress anesthetic safety
- History of previous health issues, illnesses or seizures - even if only one

Front 14

Patient History (cont.)

Back 14

- Any signs of illness in the last 24-48 hours (c/s/v/d); kittens from shelter with URI; normal water and food intake
- Any meds or preventatives (including OTC - glucosamine, flea meds, heartworm)
- Any drug allergies/adverse reactions? If get history from previous vet, just need last year's or pertinent to current problem

Front 15

Patient History (cont.)

Back 15

- Vax history
- Spayed/neutered? (cryptorchid)
- Indoor/Outdoor? cats
- Last heat cycle or poss. pregnant?
- Activity/exercise level normal? decreased and/or night coughing can indicate C/V dz; random barking at nothing could be doggie alzheimers

Front 16

Surgical Consent Form

Back 16

- Review in detail with the owner.
- Must obtain a telephone number where the owner can actually be reached in case of any issues during surgery.
- If non-owner drops off animal, must speak contact owner to obtain signature or at minimum, verbal consent and a detailed history for the animal.

Front 17

Physical Exam

Back 17

- TPR, MMs, CRT, dehydration, dental issues, abnormal heart/lung sounds, abdominal enlargement
- Always check sex of cats

Front 18

Components of the Complete PE

Back 18

- Signalment (species, breed, age, sex, weight and reproductive disposition)
- Breed important (brachycephalic, sight hounds)
- Disposition/Activity level - will help determine pre-meds and induction agents
- Exam of the animal's organ systems
- Get into a routine (e.g., head to tail with temp last)

Front 19

Exam - Step 1
Observe the overall body condition of the animal

Back 19

- Obese? Thin? Weak? Dehydrated? Pregnant?

Front 20

Exam Step 2
Examination of the Head

Back 20

- Eyes: pupils, 3rd eyelid, palpebral reflexes
- Facial symmetry, drooping, swelling
- Ears: redness, odor, pain, discharge (sniff test)
- Mouth: not painful, opens ok, gingival masses, redness, teeth, smell, carcinoma under tongue for cats (make sure animal will not bite you)
- MMs

Front 21

Exam Step 3
Observe the Pupillary Light Reflexes

Back 21

- Make sure pupils are equal and reactive (unequal could be head trauma; unreactive could mean blind)
- Direct and consensual response (eye in which light shined fully constricts and other eye partially constricts)

Front 22

Exam Step 4
Auscultation of the Heart and Lungs

Back 22

- Check heart rate: dogs 70-140 bpm, cats 110-180 bpm (above 180 in cats start looking for thyroid tumors)
- Auscult both sides of chest
- Check for gallop rhythm (3 beats instead of 2), murmur
- For cats, sometimes murmurs are best heard along the sternum

Front 23

Exam Step 4
Auscultation of the Heart and Lungs (cont.)

Back 23

- Dogs and some cats will have sinus arrhymia - HR increases on inhale and decreases when exhale (matches breathing). This is normal.
- Dogs cannot pant.
- Auscult lungs in all 4 quadrants; trachea too.
- Air or fluid in chest can muffle lung sounds

Front 24

Exam Step 5
Palpate the Pulse and Compare to the Heart Rate

Back 24

- Use the femoral artery.
- Should be a pulse for every heart beat. Will be a delay.
- If fewer pulses than heart beats, pulse deficit indicating cardiac dz

Front 25

Exam Step 6
Determine the RR and Observe for Dyspnea

Back 25

- Normals: Dogs 30/40 Cats 40/50 min.
- Dyspnea causes tachypnea, abdominal breathing - stand with elbows out and/or extend head and neck, open-mouth breathing, reluctant to lay down
- Bring to DVM's attention immediately.

Front 26

Exam Step 7
Palpate Abdomen

Back 26

- Takes practice
- Be careful with cats that have obstructed bladders - extrermely painful.
- Also be careful not to rupture cat bladders.
- Look for size, presence of fluid, gas, fetuses, feces.

Front 27

Exam Step 8
Examine Hair of the Thorax, Abdomen and Limbs

Back 27

- Thinning hair, alopecia
- Look for parasites or evidence thereof
- Part hair and look for redness, flakes, foul odor

Front 28

Exam Step 9
Observe for Lameness or Pain in Limbs

Back 28

- Observe while walking around room before put on table (cats can be difficult as they slink)
- Check if equally placing weight on all limbs.
- Check for pain, heat and swelling over joints and extremities (cats with abscesses have hot and painful areas)
- Keep large dogs on floor; have them walk over to you; observe any pain, difficulty, slowness while rising or walking

Front 29

Exam Step 10
Palpation of the Mammary Glands and Vulva in Intact Females

Back 29

- Palpate both chains of mammary glands at the same time for any masses.
- Check vulva for swelling or discharge.

Front 30

Exam Step 11
Palpate the External Lymph Nodes

Back 30

- Submandibular, prescapular, axillary, inguinal and popliteal.
- S-p-p for enlargement; in advanced cases of neoplasia, the a and i nodes may also be felt.

Front 31

Exam Step 12
Temperature

Back 31

- Dog 99-102.5; Cat 99.5-102.5

Front 32

Anesthetic Risk Classification
Class 1

Back 32

- Normal, healthy
- Routine Procedures (spay, neuter, declaw)

Front 33

Anesthetic Risk Classification
Class 2

Back 33

- Slight risk, minor disease present
- Mild systemic disturbances
- Neonate, geriatrics, obese, local infections

Front 34

Anesthetic Risk Classification
Class 3

Back 34

- Moderate risk, obvious disease
- Mild signs
- Anemia, low grade heart dz, fever

Front 35

Anesthetic Risk Classification
Class 4

Back 35

- High risk; significant dz
- Severe pre-existing dz (grade 4 of 6 heart murmur)
- Shock, toxemia, diabetes (affects BP, kidneys)

Front 36

Anesthetic Risk Classification
Class 5

Back 36

- Extreme risk
- Won't survive without sx
- Severe trauma, blocked Tom, bleeding, PCV of 10

Front 37

Anesthetic Risk Classification
Class E (Emergency)

Back 37

- Can be added to any class
- Only if an emergency
- Surgery is needed to prolong life
- Short-term blindness can result from drop in blood pressure

Front 38

Pre-Op Diagnostics

Back 38

- Hematology (PCV, QBC, CBC)
- Blood Chemistries
- UA
- Radiographs

- Ideally B/W performed for all animals undergoing anesthesia
- Many times owners refuse because of $$ or do not understand the benefits
- Always stress safety - that's why we do b/w to keep your animal as safe as possible.
- Many hospitals require b/w and a UA for geriatric patients.
- UA: Specific gravity reflects kidney function

Front 39

Explaining Pre-Op Diagnostics to Clients

Back 39

- Many diseases do not display any symptoms until well advanced. Early detection can lead to better prognosis, control and life span.
- Undiagnosed dz can increase risk of anesthesia and surgery
- The stress of anesthesia/surgery on the body may actually worsen undiagnosed and uncontrolled problems.

Front 40

Bloodwork
CBC

Back 40

- Required for geriatric screens or those previously diagnosed with infection, anemia, or thrombocytopenia; typically optional at younger ages
- Dogs: geriatric at 8y
- Cats: geriatric at 10y

Front 41

Bloodwork
CBC (cont.)

Back 41

- Measures HCT and other RBC parameters indicating anemia and the ability of the bone marrow to recover
- Can indicate evidence of previous blood loss or ongoing losses (hemolysis); hemoconcentration and dehydration
- Measures total WBC counts and the differentials of each
cell line
- Can indicate inflammation, infection, and sometimes neoplasia

Front 42

Bloodwork
Serum Chemistry Panel

Back 42

- Includes enzymes, electrolytes (may be skewed day of surgery as NPOed), glucose and nitrogenous by-products used to diagnose liver and renal dz
- Can also indicate other metabolic disorders like endocrine dz: DM (diabetes), Cushings, Addisons, Hypo-T4
- Required for geriatric patients or those with previously diagnosed liver, renal or endocrine disorders to ensure they are well-controlled
- Usually optional for younger animals

Front 43

Clotting Profiles

Back 43

- Recommended for all patients:
- Breeds known to have inherited clotting disorders (Dobies, Scotties)
- Animals with known liver dz
- Animals undergoing treatment for disorders such as immune-mediated thrombocytopenia to be sure they are well-controlled
- Animals on chemo

Front 44

FELV/FIV Tests

Back 44

- Fast and accurate in-house snap test
- Ideally run on every cat
- Status good to know for other cats in house as well as hospitalized cats
- FELV/FIV positive cats tend to have more dental issues

Front 45

Urinalysis

Back 45

- Check specific gravity, especially if BUN elevated; can indicate kidney deficit
- Checks glucose, ketones and evidence of UTI requiring treatment

Front 46

Radiographs

Back 46

- Usually reserved for those with known or suspected heart or pulmonary dz, or patients who present HBC
- Checks for pulmonary edema, pleural effusion, heart size/shape, and for HBC pulmonary contusions, pneumothorax, and diaphragmatic hernia

Front 47

Electrocardiogram (EKG)

Back 47

- Often required on geriatric patients, especially those with known heart dz
- Measures the electrical activity across the heart

Front 48

To Catheter or Not to Catheter

Back 48

- IV cath and maintenance fluids warranted for the following:
- Exploratory laparotomy; orthopedic procedures; pyometra surgery; C-section; cystotomy and other urinary tract procedures; known renal, liver and moderate to severe heart dz; thoracotomy and other procedures of the thorax

Front 49

To Catheter or Not to Catheter... (cont.)

Back 49

- Any other procedure where the time of anesthesia and surgery will be in excess of 1 hour
- Better to place a catheter and have it available if needed than to try and place one during surgery or an emergency

Front 50

Fluids

Back 50

- Helps maintain BP and makes it safer
- Healthy, geriatric patients usually receive fluids prior to or during the procedure (just in case)

Front 51

CBC/Chem Results

Back 51

- Abnormalities of the pre-op b/w should be brought to the attention of the client prior to anesthesia and the potential consequences and risks of anesthesia should they wish to proceed.
- DVM can always cancel the procedure if not in the best interest of the patient, no matter what the owner says

Front 52

IV Propofol lasts....

Back 52

Only about 20 minutes

Front 53

Why use pre-anesthetic medications?

Back 53

- Calm the patient
- Reduce/eliminate adverse reactions to general anesthesia
- Reduce amount of general anesthesia required
- Reduce surgical and post-op pain
- Allows for smoother recovery period

Front 54

Benefits of Pre-Anesthesia Medications

Back 54

- Easier, safer patient handling
- Restraint
- IVC placement
- Preemptive pain management
- Induction agent injection
- Smoother recovery
- Reduces the amount of general anesthesia required

Front 55

Pre-anesthetic meds - Drug Classifications

Back 55

- Anticholinergics
- Sedatives/Tranquilizers
- NSAIDS
- Opioids

Front 56

Classification of Pain

Back 56

- Physiological: recognition of sensation from heat, cold or pressure
- Pathological: result from inflammation or neuropathic processes

Front 57

Nociception - Definition

Back 57

Special kind of nerve cell in skin and deep tissues.
Transduction, conduction and central nervous processing of signals generated by the stimulation of the nociceptors. Nociceptors send nerve impulses along a chain of at least 3 neurons

Front 58

Nociceptors
aka Pain Pathway
- The Four Phases

Back 58

- Transduction: noxious stimuli to the nociceptor; stimulus of sensory nerve endings
- Transmission: propagation of the nerve impulses thru the peripheral nervous system
- Modulation: occurs in the spinal cord which modifies the transmission of the stimuli; neurotransmitters involved
- Perception: final process that will deviate the animal's behaviour and emotional response (crying, chewing, BP)

Front 59

Principles of Pain Management

Back 59

- Preemptive analgesia: prevention of potential pain caused by procedure
- Multimodal analgesia: using various drug classes to interrupt pain pathways at various points (e.g., opiods and NSAIDS)
- Follow-up post-op analgesia: give appropriate post-op pain meds and send home meds for further pain control as needed

These facilitate quicker healing times and reduce patient and owner stress

Front 60

Balanced Analgesia - Definition

Back 60

Application of two or more classes of analgesics that interfere with nociceptions. Ex: giving hydromorphone and glyco IM, then placing a lumbar epidural after induction, then NSAID post op.

Front 61

Anticholinergic Drugs - Effects and Examples

Back 61

- Dry secretions
- Decrease GI motility
Examples: Atropine, Glycopyrrolate

Front 62

Anticholinergic Drugs - Atopine - Details

Back 62

- Given IM, SQ or IV
- Quicker uptake but shorter lasting than glyco
- Blocks stimulation of the vagus nerve
- Contraindicated in animals with pre-existing tachycardia
- Crosses the blood/brain barrier
- Used for CPCR

Front 63

Anticholinergic Drugs - Glycopyrrolate - Details

Back 63

- Given IM, SQ or IV
- More safety factors than Atropine; safer to use in some animals with preexisting heart conditions
- Does not decrease GI motility
- Does not cross the blood/brain barrier

Front 64

Sedatives and Tranquilizers- Effects and Examples

Back 64

- Reduce anxiety (tranquilizer) but do not necessarily reduce awareness
- Reduce mental activity and cause sleepiness (sedative)
- NO analgesia except for alpha-2 agonists

Examples: Phenothazines (Acepromazine maleate, chlorpromazine) - sedatives
Benzodiazepines (diazepam, midazolam, lorazepam, zolazepam) - tranquilizers
Alpha-2 Agonists (Xylazine, Medetomidine)

Front 65

Sedatives - Phenothiazines (Details)

Back 65

- Can be given orally or paternally
- Can cause hypotension and hypotheria
- Do not provide any analgesia
- No reversal agent (agonist)

Front 66

Tranquilizers - Benzodiazepines (Details)

Back 66

- Not real effective as stand-alone drug in healthy, younger patients
- Good muscle relaxant
- Often given to cats as appetite stimulant
- Minimal cardiac and respiratory adverse effects
- Diazepam excellent anticonvulsant; NOT water soluable
- Do not provide any analgesia
- Reversal agent: flumazenil

Front 67

Sedatives - Alpha-2 Agonists (Details)

Back 67

- Potent sedatives
- DO provide analgesia
- Often used alone for short minor procedures
- Potential for cardiac side effects, s/b used in healthy animals only
- Can make animals sensitive to noise stimuli
- Xylazine used to cause vomiting in cats, too
- Yohimbine reversal agent for Xylazine
- Medetomidine (Domitor) similar to Xylazine; reversal agent is Atipamezole (Antisedan)

Front 68

Opioids - Types and Examples

Back 68

Agonist: Morphine, hydromorphone, oxymorphone, Fentanyl

Agonist-Antagonist: Butorphanol, Burprenorphine

Antagonist: Naloxone

Front 69

Opioids - Effects

Back 69

- Excellent pain relieving properties
- Sedative effects
- Wide safety margin
- Often used in combo with tranquilizers to attain a state of neuroleptanalgesia
- Some are addictive
- Can cause respiratory effects
- Can initial increase GI activity then decrease
- Many are controlled substances

Front 70

Opioids - Effects (cont)

Back 70

- Morphine can make cats freaky
- Fentanyl 80-100 xs more powerful than morphine
- Butorphanol doesn't provide great analgesia

Front 71

NSAIDS - Examples

Back 71

Meloxicam (Metacam) - oral and injectable
Carprofen (Rimadyl) - dogs only
Ketoprofen

Front 72

Factors that Influence Preanesthetic Selection

Back 72

- Physical status
- Availability of facilities and equipment
- Familiarity with the drugs
- Nature of the procedure (e.g., how much pain will it cause?)
- Special circumstances (congenital defects)
- Cost
- Speed of the procedure/drug

Front 73

Controlled Substance Log - Definition and Requirements

Back 73

DEA requires that certain "controlled" substances (addictive) must be recorded in both a log and the patient record
- Must conduct every two year inventory
- Log must have bound pages, include date, client, patient, drug, amount (drawn and given), and balance on hand
- Purchase records for CII retained and kept on the premises
- Log and all records must be maitained for two years.

Front 74

Controlled Substance Storage

Back 74

- Drugs must be stored in a double-locked cabinet; specific for these drugs
- Mobile units should have enough drug for basic operations

Front 75

Sub Q Injections: Info

Back 75

- Generally less painful
- Longer absorption rate
- Tent loose skin on back of neck
- Always Aspirate!!!
- Massage site
- Absorption takes about 30-40 mins
- Usually injected at 45 angle

Front 76

IM Injections

Back 76

- Generally more painful than others
- Use 25 gauge needle and change if poke more than 1X
- Sudden movement can cause tissue damage
- Avoid giving over 2 ml at a time per site
- Give slowly ~ 15 secs
- Sites quadriceps, lumbar muscles (use 90 angle)
**Avoid Sciatic**
- Massage area
- Effect takes about 15-20 mins

Front 77

Injection Needles -

Sizes

Back 77

- Smaller the number, the larger the needle size (inversely related)

Examples:
- 18 gauge huge, fluid administration
- 25 gauge tiny

Front 78

Intubation: Info

Back 78

- Once plane of anesthesia sufficient (Stage 3, Plane 2) place tube
- Should have cuffed tube (except neonates)

Cuff Info
- Overinflation can cause bent tip and occlude part of the opening causing obstructon
- Trachea can rip
- Underinflation can cause gas leak, animal too light, $$ wasted in gas

Front 79

Monitoring Patient Under Anesthetic w/o Machines

Back 79

- Estimate blood O2levels by mm color
- Determine HR via pulse/auscultation or esophageal stethescope
- RR via auscultation, esophageal stethescope or watching chest

Front 80

LVT's Role in Monitoring Anesthesia

Back 80

- Take vitals before anesthesia
- Check vitals every 5 mins
- Record HR, RR, SPO2, EKG, BP and CO2

Front 81

Anesthetic - Rebreathing Systems

Back 81

- Typically used for patients over 10 lb.
- Use less O2 and anesthetic
- Less waste gasses are produced
- Heat and moisture from patient's respirations are conserved

Front 82

Anesthetic - Non-Rebreathing Systems

Back 82

- Can be used for patients under 10 lb.
- Depth of anesthesia can be changed more rapidly
- Less resistenace occurs during respirations (small animals may have difficulty inhaling with enouth force to draw air through a rebreathing system)

Front 83

Evaluating a Patient's Anesthetic Depth

Back 83

**Using IV agents can make it difficult to differentiate planes**

Too Light: Signs of excitement, motor activity, unwanted reflexes (blink, swallow, chew), tachycardia and tachypnea

Too Deep: Cardiovascular and respiratory systems dangerously depressed

Front 84

Anesthetic Landmarks

Back 84

- Analgesia and amnesia
- Loss of motor coordination
- Loss of consciousness
- Reduction of protective reflexes (gag, blink)
- Blockage of afferent stimuli
- Muscle relaxation
- Respiratory and cardiovascular depression
- Apnea
- Cardiovasculat standstill
- Death

Front 85

Anesthesia -

Stage 1 Description

Back 85

- Excitement phase
- Struggling and breath holding
- RR and pulse rate increase
- Pupils are dilated (flight/fight)
- Urination and defecation frequently occur
- Fear responses

Front 86

Anesthesia -

Stage 2 Description

Back 86

- Loss of consciousness occurs
- Ventilation is irregular
- Involuntary excitement may (and will) occur

Front 87

Anesthesia -

Stage 3 Plane 1 Description

Back 87

- Painful stimuli will result in increased HR, BP and RR
- Palpebral reflex is present
- Eye is centrally positioned
- Pedal reflex is present
- Adequate plane for radiographs, nail trims and other quick non-painful procedures
- NO SX

Front 88

Anesthesia -

Stage 3 Plane 2 Description

Back 88

- Laryngeal reflex is not present (swallow, gag)
- Further depression of cardiopulmonary system
- Eyes rotate downward in dogs and cats
- Palpebral and pedal reflex is lost
- Appropriate for most SX

**Need to be here to correctly intubate**

Front 89

Anesthesia -

Stage 3 Plane 3 Description

Back 89

- Respiration becomes further depressed
- Cardiac contractility and BP decrease
- Eyes in dogs and cats return to central alignment
- Typically this is too deep and gas s/b reduced
- Used for amputations, TPLO SX where pain will cause animal to go up to Plane 2

Front 90

Anesthesia -

Stage 3 Plane 4 Description

Back 90

- Overdose
- Paralysis of intercostals; suppressed respiration
- Abdominal breathing very pronounced
- If uncorrected paralysis of medulla and CV collapse
- Recovery possible if gas turned off and ventilated on O2
- If not noticed, animal will die

Front 91

Hypocapnic - Definition

Back 91

- Respiratory alkalosis
- Condition in which increased respiration (hyperventilation) elevates the blood pH
- Blood CO2 decreases
- Can cause: patient to be too light
- Some drugs (oxymorphone) and panting cause this

**need to change the anesthetic plane**

Front 92

Hypercapnic

Back 92

- Respiratory acidosis
- Condition in which decreased respiration (hypoventilation) causes increased blood O2 and decreased pH
**Increase ventilation**
**Check CO2 granules - hard means expired

Front 93

Cardiac abnormalities

Back 93

Bradycardia: too deep, drugs, hypothermia, vagal stimulation
- Give anticholinergics
- Prevent or reverse hypothermia

Tachycardia: not frequently seen in SX, possibly with no pain med
- Patient is too light
- Increase fluids (SX rate 10 mls/kg/hr)

Front 94

Hypotension

Back 94

- Patient is too deep under anesthetic
- Vasodilation
- Positioning
- Decrease anesthetic
- Give Fluids
- Dobutamine to increase cardiac output

Front 95

Hypertension

Back 95

Patient is too light under anesthetic

Front 96

Assessing Patient Circulation

Back 96

- Pulse palpation (distal)
- EKG
- Indirect and direct BP
- Esophageal stethescope
- Regular stethescope
- CRT

Front 97

Assessing CRT

Back 97

Provides a crude indication of hydration status and peripheral perfusion (circulation)

Front 98

Normal Canine and Feline Blood Pressure Values

Back 98

Systolic: 90-160 mmHg
Diastolic: 50-90 mmHg
Mean Arterial Pressure (MAP): 70-100 mmHg

Ideal:
Systolic: 110-120
Diastolic: Varies
MAP: 80

**Surgeon can feel the mesenteric artery for the pulse**

Front 99

Blood Pressure - Definition and Characteristics

Back 99

Force exerted by the blood against the inner walls of vessels
- Rises and falls in coordination with cardiac cycle
- Higher on systole, lower on diastole (we look for systole)
- Maintains proper tissue perfusion

Check 3 in a row then average
Use top of rear paw to measure (per Maryam)

Front 100

Blood Pressure - Monitoring

Back 100

Indirect:
- Cuff must be on an artery
- To measure cuff, place it lengthwise on the paw; if less than 40% wide in width, s/b a good size

Direct:
- Requires an arterial catheter; not used that often

**Typically looking for systolic but in time you will hear diastolic**

Front 101

Pulse Oximeter

Back 101

- Assesses tissue perfusion
- Monitors pulse rate
- How much available hemoglobin is saturated in O2 (SPO2)
- Should be greater than 95%

Lingual clip shines light; reflected off RBCs which determines O2 %

Place light part on underside of tongue as blod vessels closer to surface on underside

Front 102

Capnograph

Back 102

- Measures end title CO2 in expired breath
- Directly related/correlated to cardiac output
- Much more sensitive indicator of hypoventiliation than Pulse Ox
- Normal values 35-45 mmHg
- Displays as a wave

**Too much O2 can become toxic

Front 103

Electrocardiogram (EKG)

Back 103

Used to identify abnormalities with the cardiac conduction system
- Illustrates the electrical activity of the heart
- Must see a "P" wave for every "QRS" complex
- Not unusual to see occasional VPCs while animal anesthetized
- Sinus bradycardia normal with Domitor

Front 104

Respiration Monitoring - Why and Methods

Back 104

To ensure adequate O2 concentration in the patient's arterial blood and patient's ventilation is adequately maintained

Methods:
- Observe MM color
- Pulse ox
- Thoracic wall movement
- Capnography (expelled CO2)
- CRT

Front 105

Causes of Hemoglobin Desaturation

Back 105

- Disconnection of equipment
- O2 tank empty
- Airway obstruction (kinked tube) - dentals
- Apneustic breathing
- Manual errors (probe, dry tongue, motion)
- Hypotension

Front 106

Recovering Animals from Anesthesia and Monitoring Post Op

Back 106

- Gentle physical stimulation
- Ventilation if necessary
- Fluid therapy if necessary
- Reversal agents
- Warming measures
- Dextrose if needed
- Palpebral and ear flick
- HR, RR and MM
- Temp must be 99.9 before you can leave alone
- S/B in sternal recumbancy; if lateral, make sure to turn them to both lungs can expand

Front 107

Laryngoscope

Back 107

- Helpful with intubation
- Provides a light source
- Can be used to gently manipulate tissues so the airway is better exposed
- Typically makes intubation less traumatic and less likely to intubate esophagus
- Helps you find tumors, tonsils, issues, etc.

**Always pull tongue up and out**

Front 108

EKG Lead Placement

Back 108

White - always on the right (front)
Green - below white (right rear)
Black - Smoke covers fire (front left)
Red- Fire (left rear)
Brown is ground

Front 109

"To Do" Before Anesthetizing and Prepping a Patient

Back 109

- Physical exam
- Check record to ensure you have the correct patient
- Diagnostic tests
- Double check drug dosages (pre-meds, induction agents)
- Prep SX room (packs, anesthesia machine)
- New or clean clipper blades (non chipped)

Front 110

Patient Prep - Clipping - Equipment and Materials Needed

Back 110

- Clippers
- Clipper cleaner
- Clipper brushes
- Surgical scrub
- Gauze or sponges
- Prepuce flushing materials (6-12 cc syringe, bowl, cleaning solution)
- Vacuum
- Lint roller

Front 111

Clipping and Hair Prep

Back 111

- Position patient for the SX - better to clip too much than too little
- #40 blade
- Clip against grain of the hair
- If long hair (feathers) trim edges nbear the SX site
- Vacuum hair thoroughly
- Lint roller
- Express bladder and flush prepuce

Front 112

Shaving - General Guidelines

Back 112

Soft Tissue: 2 clipper blade widths every direction from the proposed SX site
Orthopedic: clip limb from the joint distal to and promixal to the incision site all the way around the limb
Vertebral: 1 space cranial and 2 spaces caudal to the affected site or extend to the most cranial and caudal spaces affected

Front 113

Skin Prep - Povidone Iodine

Back 113

- 50/50 dilution
- Wide spectrum antimicrobial
- Low tissue toxicity
- Inexpensive and readily available
- Stains
- Low residual effect

Front 114

Skin Prep - Chlorhexidine Gluconate

Back 114

- 60/40 dilution
- Residual effects up to 2 hours
- Wide spectrum
- Low tissue toxicity (except mm)
- More $$ than povidone/iodine
- No stain

Front 115

Skin Prep - Rinsing Agents - 70% Isopropol Alcohol

Back 115

- Effective against G- bacteria
- Well tolerated by most patients
- Inexpensive and readily available
- Can be used with either scrub
- Evaporates quickly (good and bad)
- Irritates mms, open wounds, eyes
- Helps get rid of the soap

Front 116

Skin Prep - Rinsing Agents -
Sterile H2O, Sterile Saline

Back 116

- Effective at removing scrub
- No antimicrobial properties
- Used with open wounds, eyes, mms
- Practical and reasonable when alcohol is contraindicated

Front 117

Prepuce Flush Procedure

Back 117

- Do for all abdominal SX
- Do prior to skin prep
- After hair removed from the prepuce:
- 1:10 povidone/iodine solution with water
- Insert syringe (no needle) into prepuce and inject 5 ml of solution
- Pinch tip and gently massage
- Release and absorb solution in a towel
- Repeat

Front 118

Scrubbing Patterns

Back 118

Target:
- Used for abdominal, thoracic, neuro
- Looks like a bullseye
Orthopedic:
- Once hair removed must cover rest of foot with glove, tape, vet wrap. Scrub limb distal to proximal all the way around the limb
Perineal:
- Purse string suture in anus
- 3 target patterns to left of anus, to the right and the anus itself

Front 119

Draping the Patient -

Two Types of Drapes

Back 119

- Fenestrated, sterile drape placed over area and secured with towel clamps
- Four corner drape - Houck towels placed clockwise or counterclockwise

Front 120

Draping the Patient -

Procedure

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- Float the drape above the patient (do not drag)
- Make sure sterile drape is in between the surgeon's sterile gown and the unsterile (undraped) surgical table
- Drape should be only adjusted minimally after placement; ok to adjust away from sterile site but NEVER towards
- Towel clamps are not to be laying on the patient's skin

Front 121

Suture Material -

Characteristics and Terms Used to Describe

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- Tensile strength - amount of pull or weight needed to break suture
- Memory (how it retains the shape it was in the package)
- Flexibility (bigger is less flex)
- Absorbability
- Structure
- Know security
- Color
- Origin of material
- Sizing
- Packaging
- Plain (not treated with anything)
- Chromic (treated with acid salts to delay absorption)
- Capillary (the ability to draw liquids; braided)

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Suture Material -

Absorbable

Back 122

- Break down anywhere from
10 days-8 wks (typically)
- Used when prolonged strength not requires or when infection present
- Made from gut, synthetic polyester, lactic and glycolic acid
- Dexon, Vicryl, Ethicon, PDS, Maxon

Front 123

Suture Material -

Non-Absorbable

Back 123

- Require removal unless becoming a permanent part of the structure
- Used when tissue reaction must be minimized, when must be left in longer, such as immunocompromised patient
- Made from silk, cotton, stainless, synthetic plastic
- Ethilon, Prolene, Dermalon, Ethibond

Front 124

Suture Material -

Monofilament vs Multifilament

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- Mono: one strand
- Multi: braided like; lots of wicking properties; absorbs faster; used in mouth

Front 125

Suture Material -

Size

Back 125

- Size standardized by USP - United States Pharmacopeia
-Large to small: 4, 3, 2, 1, 0, 1-0, 2-0, 3-0, 4-0
- 0 pronounced "ought"

- Wire suture has own gauging system 18-40; the lower the number the thicker the diameter

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Suture Patterns -

Interrupted

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- Advantages: If one suture breaks, the rest are ok; minimize travel of bacteria
- Disadvantages: More operator time; more suture used, knots
- Patterns: Simple Interrupted, Vertical Mattress, Horizontal Mattress, Cross-Mattrress Cruciate

Front 127

Suture Patterns -

Continuous

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- Advantages: Strong; minimal use of material/knots
- Disadvantages: If one breaks, the whole line is shot; bacteria can travel up the entire length of the suture
- Patterns: Simple Continuous, Ford Interlocking Blanket Stitch

Front 128

Suture Needles -

Anatomy

Back 128

- Point
- Body (shaft)
- End (swagged or eye)

- Curved most commonly used
- 1/2 and 3/8 = abdominal
- 1/4 = eyes
- 5/8 = stifle
- Straight for necropsies

Made of stainless steel or carbon

Front 129

Suture Needles -

Tapered or Non-Cutting

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- Comes to a point at the end
- Pokes a hole in tissue
- Used on delicate tissue (intestines or hollow organs)

Front 130

Suture Needles -

Cutting

Back 130

- Conventional: Triangle shape; most traumatic to tissues
- Reverse: Upside-down triangle
- Sharp like a scalpel
- Designed to cut tissue when needle passes through
- Used on tougher tissues like skin, cartilage

Front 131

Suture Needles -

Swagged vs Non-Swagged

Back 131

- Swagged: eyeless needle attached by the manufacturer; specific length of suture thread; swag is smallest part of needle
- Non-Swagged or Eyed: Have holes or eyes; suture must be threaded on site; tend to cause more trauma to the site

Front 132

Skin Staplers

Back 132

- GIA: Foreign body or tumor removal in large/small intestine; no leakage (prevents peritonitis)

- TA: Liver/lung lobes; good for soft tissue that's difficult to suture

Front 133

Wound Healing Phases - Major 4

List

Back 133

#1 - Inflammation with two sub-phases a)vasoconstriction b) vasodilation
#2 - Debridement
#3 - Repair
#4 - Maturation

Front 134

Wound Healing -

Inflammation Phase

Back 134

- Vasoconstriction occurs immediately after wound occurs to help control bleeding
- Vasodilation occurs within a few minutes of wound; Neutrophils are predominant cell; cells adhere to vascular endothelium; within 30 minutes leukocytes migrate

Front 135

Wound Healing -

Debridement Phase

Back 135

- Monocytes are critical cells
- Mature into macrophages
- Phagocytizes debris to clean the wound

Front 136

Wound Healing -

Repair Phase

Back 136

- Fibroblasts, capillary migration, epithelial proliferation
- Form collagen matrix (scaffolding) that allows epithelial cell migration later
- What you see at this point is scar tissue

Front 137

Wound Healing -

Maturation Phase

Back 137

- Newly laid collagen fibers reorganize along lines of tension in the skin
- Non functional replaced as functional
- Wound gains additional strength but will never be as strong as original tissue; abut 15-20% weaker than surrounding tissue
- Takes up to two years to finish this phase

Front 138

Types of Wound Healing -

First Intention

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- aka Primary Intention
- Characterized by a non-complicated healing process
- Ex. minor lacerations, clean wounds

Front 139

Types of Wound Healing -

Second Intention

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- Characterized by wounds that are left open to heal
- Ex. large wounds, infected wounds, left to granulate in

Front 140

Types of Wound Healing -

Third Intention

Back 140

- Originally starts as 2nd intention but requires surgical intervention
- Ex. severely infected, very large wounds